Name of Learner: Deniell M.

Corpuz __________________ Date: May 21, 2021____

Year/Section: BSN III-D_________________ RLE Group: I__________

Case Vignette

Disorder: Wet form of Macular Degeneration

1. What other data you need to gather from Mrs. Insyang to determine whether a
macular degeneration has likely occurred?
Mrs. Insyang has been eye examined first by the physician to identify the need for
treatment. During the examination, it also vital to ask questions regarding history of the
client:

Sample questions:
• Do you have a family member with this kind of disease?
• Do you often eat food with high cholesterol? – high glycemic diet is associated with
AMD onset and progress.
• Do you smoke? If yes, how many sticks a day? – smoking is associated with
destruction of blood vessels, reduced oxygen flow, fewer nutrients circulating in the
body, and higher rates of harmful chemicals in the body, which can lead to retinal
damage, specifically in the macula.
• Do you have high blood pressure? – researchers also found that beta blockers like
Tenormin and Lopressor increased the risk of neovascular or wet AMD.

Screening test must also be used to have better foundation of information.

2. What type of macular degeneration is likely to be? Justify your answer.

The patient is suspected having Wet form ARMD. Mrs. Insyang stated that she has
been noticing a change in her vision over the past couple of months upon consultation. She
also admitted she can no longer read small print, even with her usual reading glasses. In
addition, she said there is always a slight smudge in her sight and lines always appear wavy
rather than straight.

According to CDC (2016) wet form (exudative, neovascular) ARMD, it has an abrupt
onset and more damaging to the vision. Blood vessels grow from underneath the retina,
within the choroid layer of the eye causing choroidal neovascularization. These blood
vessels leak blood and fluid into the retina. Causing vision distorted and that the straight
lines look wavy. It may also cause blind spots and loss of central vision. These blood vessels
and their bleeding eventually form a scar, leading to permanent loss of central vision. In
some instance, I doubt on diagnosing a patient if there is no confirmatory test done like
fluorescein angiography to detect if there is angiogenesis and bleeding that causes seeping
or exudation in the eyes that eventually causes blur of vision or blind spot. I derived the
diagnosis based from the knowledge that dry ARMD doesn’t usually causes blind vision
while in wet ARMD because of angiogenesis there may be a bleeding that may cause blind
spot of vision distortion.

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 3. What possible etiology/risk factors that led to the development of Mrs. Insyang’s
d/o?

• Age. The number one risk factor is age. One-third of adults over 75 are affected by
AMD.
• Smoking. Smoking increases a person’s chances of developing AMD by two to five-
fold. Because the retina has a high rate of oxygen consumption, anything that
affects oxygen delivery to the retina may affect vision. Smoking causes oxidative
damage, which may contribute to the development and progression of this disease.
• Family History of AMD. A person is more likely to develop AMD if someone in his
or her immediate family has had it.
• Gender. Females are more likely to develop AMD than males. This factor may be
because females live longer than males, and thus have more time to develop the
disease.
• Race. Caucasians are more likely to develop AMD than other races. This factor may
be related to differences in genetic background or pigmentation.
• Prolonged Sun Exposure. Although the evidence is not conclusive, some studies
suggest an association between AMD and cumulative eye damage from ultraviolet
(UV) and other light. This light may damage the retina and increase the risk of AMD.
• Diet. People with diets that are elevated in fat, cholesterol and high glycemic index
foods, and low in antioxidants and green leafy vegetables may be more likely to
develop AMD. High-glycemic index foods, such as white rice, bread and pasta raise
blood sugar rapidly, whereas low-glycemic foods, such as whole grain breads or
oatmeal can lower the risk of AMD by stabilizing blood sugar levels.
• Obesity. A person with a BMI (body mass index, a measure of body fat) of greater
than 30 is 2.5 times more likely to develop the disease than a person with a lower
BMI.
• High Blood Pressure. High blood pressure, like smoking, leads to a constriction
(narrowing) of the blood vessels that nourish the retina, restricting oxygen flow.
• Eye Color. People with light-colored eyes are more likely to develop the dry type of
AMD. This factor may be because light-pigmented eyes offer less protection from
damaging UV light.
• Inactivity. In dry AMD, the retina does not receive adequate oxygen, leading to the
death of cells in the macula. Exercise improves cardiovascular health and might help
prevent AMD.
• Presence of AMD in One Eye. If a person has AMD in one eye, he or she is more
likely to develop it in the other eye.

4. What test/s and/or diagnostic procedure should be done to confirm the

diagnosis? Elaborate your answers.

Based on the case of Mrs. Insyang, she was performed with an eye examination.
The physician might have diagnosed Mrs. Insyang’s condition by reviewing her medical and
family history and conducting a complete eye exam. The physician may also do several
other tests, including:
• Examination of the back of your eye. Your eye doctor will put drops in your eyes to
dilate them and use a special instrument to examine the back of your eye. He or she
will look for a mottled appearance that's caused by drusen — yellow deposits that
form under the retina. People with macular degeneration often have many drusen

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 (Drusen are the defining feature of macular degeneration. These small yellow or
white spots on the retina.)
• Ophthalmoscopy. Ophthalmoscope is an instrument used for examining the
interior structures of the eye, especially the retina. It consists of a mirror that
reflects light into the eye and a central hole through which the eye is examined.
Your doctor will be able to detect any damage or changes in the retina and macula.
• Test for defects in the center of your vision. During an eye examination, your eye
doctor may use an Amsler grid to test for defects in the center of your vision.
Macular degeneration may cause some of the straight lines in the grid to look faded,
broken or distorted.
• Fluorescein angiography. During this test, your doctor injects a colored dye into a
vein in your arm. The dye travels to and highlights the blood vessels in your eye. A
special camera takes several pictures as the dye travels through the blood vessels.
The images will show if you have retinal changes or abnormal blood vessels, which
are a sign of wet macular degeneration.
• Indocyanine green angiography. Like fluorescein angiography, this test uses an
injected dye. It may be used alongside a fluorescein angiogram to identify specific
types of macular degeneration.
• Optical coherence tomography. This noninvasive imaging test displays detailed
cross-sectional images of the retina. It identifies areas of retina thinning, thickening
or swelling. These can be caused by fluid accumulation from leaking blood vessels
in and under your retina.

5. What treatment should be offered to patient Insyang?

As of now, there's no treatment for dry macular degeneration. However, there are
many clinical trials in progress. If your condition is diagnosed early, you can take steps to
help slow its progression, such as taking vitamin supplements, eating healthfully and not
smoking. Treatment varies depending on the type of AMD and individual characteristics of
the condition. Various treatments available for wet AMD include:

6. Ranibizumad (Lucentis), Aflibercept (Eylea) and Bevacizumab (Avastin) drugs are

the most common treatments used. These drugs are injected into the vitreous
cavity of the eye, reducing leakage from the blood vessels under the retina. Since
this is not a cure, the majority of patients receiving these treatments will require
lifelong therapy at 1-3 monthly intervals.
7. Photodynamic Therapy (PDT) is a specialized laser therapy combining injection of a
photosensitive drug called Verteporfin into the blood stream followed by laser
treatment. Both works together to seal the leaky blood vessels without causing
damage to other parts of the eye and this is particularly effective in treating in a
variant of wet AMD called idiopathic polypoidal choroidal vasculopathy, commonly
seen in Asian and Indians. For these patients, PDT may reduce the need for
continuous treatment with injections as mentioned above.
8. Laser Photocoagulation is a concentrated beam of high energy laser light, directed
onto the retina, to seal the leaky blood vessels. If this treatment modality is suitable,
it may reduce the need for on-going treatment with injections.
9. Surgery to implant a telescopic lens - For selected people with advanced dry
macular degeneration in both eyes, one option to improve vision may be surgery to

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 implant a telescopic lens in one eye. The telescopic lens, which looks like a tiny
plastic tube, is equipped with lenses that magnify your field of vision. The telescopic
lens implant may improve both distance and close-up vision, but it has a very narrow
field of view. It can be particularly useful in an urban environment to aid in
identifying street signs.
10. Low vision rehabilitation. Age-related macular degeneration doesn't affect your
side (peripheral) vision and usually doesn't cause total blindness. But it can reduce
or eliminate your central vision — which is necessary for driving an automobile,
reading and recognizing people's faces. It may be beneficial for you to work with a
low vision rehabilitation specialist, occupational therapist, your eye doctor a nd
others trained in low vision rehabilitation. They can help you find ways to adapt to
your changing vision.
11. Nutritional supplements. The Age-Related Eye Disease Study (AREDS) found that a
combination of vitamins and minerals may slow the progression of dry AMD. AREDS
supplements include vitamin C, vitamin E, lutein, zinc, copper, zeaxanthin and beta
carotene. (Smokers shouldn’t take beta carotene because it raises the risk of lung
cancer.)
12. Antivascular endothelial growth factor (anti-VEGF). This treatment for wet AMD
blocks the production of VEGF, a protein that produces new blood vessels. Your eye
healthcare provider injects anti-VEGF into a numbed eye. The drug slows or stops
blood vessel development. This treatment sometimes improves vision.

13. What are the important pharmaceutical considerations in managing Mrs.

Insyang’s condition?

For wet macular degeneration:

• Angiogensis Inhibitors Angiogenesis inhibitors work by blocking the activity of
vascular endothelial growth factor (VEGF), a protein that promotes blood vessel
growth. Four treatments for wet AMD using angiogenesis inhibitors—brolucizumab
(Beovu®), aflibercept (Eylea®), ranibizumab (Lucentis®), and pegaptanib sodium
(Macugen®)—were approved by the U.S. Food and Drug Administration (FDA) in
2019, 2011, 2006, and 2004 respectively.
• Beovu is also prescribed as an injection to be given in the vitreous of the eye after
it has been numbed. It is the only anti-VEGF agent recommended up to three-month
dosing intervals in eligible patients. The treatment with other anti-VEGF agents is
typically given at every 4-6 weeks frequency.
• Eylea. After numbing the eye, the doctor injects Eylea into the clear, jelly-like
substance (the vitreous) that fills the eye from the lens back to the retina and then
monitors the patient’s progress. After an initial three-month period of injections
every four weeks, Eylea can be administered every eight weeks.
• Lucentis is also injected into the vitreous portion of the eye after it has been
numbed. Injections are given regularly over a period of time. The frequency and
actual number of injections needed are determined by the physician and the
individual patient’s disease status and response to treatment.
• Macugen is also injected into the vitreous portion of the eye that has been numbed.
It is usually administered every six weeks. The actual number of injections needed
is determined by the physician, taking the individual patient’s disease status and
response to treatment into consideration. Macugen is still available for treatment
of wet AMD, but is not used as often as other injectable angiogenesis inhibitors.

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 • Avastin is an FDA-approved cancer therapy drug manufactured by the same
company that makes Lucentis. Avastin has been used by doctors as an off-label
treatment for AMD. Both drugs are similarly administered. However, Avastin is
much less expensive, and many doctors believe these drugs are equally effective
against macular degeneration
• What are the nursing management indicated for patient Insyang? Prioritize.

Risk for Injury

• In prevention injury of Mrs. Insyang instruct family members to make sure there is
plenty of light in entries and stairs in their home
• Instruct them to also mark these areas with paint or tape so Mrs. Insyang can easily
see them.
• Tell them to also use dark switch plates on light walls and light ones on dark walls
• Provide large print objects and visual aids for teaching.
• Encourage patient to see an ophthalmologist at least yearly.
• Wear sunglasses. Buy ones that protect you from ultraviolet A and B (UVA and UVB)
rays.
• Include plenty of fresh fruits and dark green, leafy vegetables (such as spinach and
collard greens) in your diet. Your doctor may also want you to take a vitamin and
mineral supplement.
• Quit smoking. Smoking can make this condition worse. If you need help quitting,
talk to your doctor about stop-smoking programs and medicines. These can increase
your chances of quitting for good.
• Try these tips to make your life at home easier and safer:
o Point lighting at what you want to see and away from your eyes. Add lamps
in dark places.
o Prevent falls by making sure there is plenty of light in entries and stairs. You
may also want to mark these areas with paint or tape so you can easily see
them.
o Make your light switches easier to see. Use dark switch plates on light walls
and light ones on dark walls. You can also use switches that glow.
o Use paint or tape to mark electrical outlets, thermostats, and other items
you need to find.
o Use bold black letters to make labels, signs, and other markings. Label your
medicines clearly.
o Use a magnifier to help you read. Or choose large-print books. If you still
need help, ask your doctor about other vision aids.

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 References:

2017, 15 A. (2021, February 12). Wet age-related macular degeneration: case study. The
Pharmaceutical Journal. https://pharmaceutical-journal.com/article/ld/wet-age-
related-macular-degeneration-case-study.

Age-Related Macular Degeneration: Care Instructions. MyHealth.Alberta.ca Government of

Alberta Personal Health Portal. (n.d.).
https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid
=ut1929.

Age-Related Macular Degeneration: Symptoms & Treatment. Cleveland Clinic. (n.d.).

https://my.clevelandclinic.org/health/diseases/15246-age-related-macular-
degeneration.

Macular Degeneration: Prevention & Risk Factors. BrightFocus Foundation. (2020, February
10). https://www.brightfocus.org/macular/prevention-and-risk-factors.

Mayo Foundation for Medical Education and Research. (2021, May 8). Dry macular
degeneration. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/dry-
macular-degeneration/diagnosis-treatment/drc-
20350381#:~:text=During%20an%20eye%20examination%2C%20your,Fluorescein%20
angiography.

Person. (2021, February 8). Amsler Grid: A Test for Macular Degeneration and Other Vision
Problems. All About Vision. https://www.allaboutvision.com/conditions/amsler -
grid.htm.

Vera, M., By, -, Vera, M., & Matt Vera is a registered nurse with a bachelor of science in nursing
since 2009 and is currently working as a full-time writer and editor for Nurseslabs.
During his time as a student. (2019, April 10). 2 Macular Degeneration Nursing Care
Plans. Nurseslabs. https://nurseslabs.com/macular-degeneration-nursing-care-plans/.

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